Fire Insurance on Buildings

OTHER PERTINENT INFORMATION

$ ____ _ Other Liabilities Due Within One Year

Describe $ _____ _

Have you ever made a compromise settlement with creditors or been adjudged bankrupt in the last 10 years? _______________ _

Are any suits, judgements or litigation pending either for or against you? ____________________________ _

The undersigned hereby represents and guarantees that the foregoing statement is in all respects true and correct as of the above stated date. In the event of any material change in the financial condition, as set forth herein, the undersigned agrees to notify said financial institution immediately in writing. I also agree to furnish current financial information upon request. You are authorized to contact any appropriate third parties for the purpose of verifying any information furnished by me (us), and/or securing additional credit information at any time as deemed necessary.

Date Signed

STATE OF

COUNTY OF } ss.

Signature

Signature of Joint Individual

-------------- being duly sworn on oath, deposes and says that he is the person who signed the above and foregoing instrument; that he has read the contents thereof, both written and printed matter. and that the same are true and correct.

Subscribed and sworn to before me this ______ day of _________ _ (Seal) Notary Public _____________________ _

My commission expires ________ _